Discussion of interesting or befuddling cases related to pulmonary and critical care medicine.

Monday, November 21, 2005

Consult to "bronch"

We were asked to consult on a patient to "rule out endobronchial lesion via bronch".A 52-year-old male has an unremarkable past medical history. He has a 100 pack-year histor and is an alcoholic. He noticed a "boil" over his "right collar bone". He thought maybe he was bitten by an insect. Since then has had progressivesymptoms resulting in chest pain and difficulty breathing.Blood pressure 120/70, heart rate 120, respiratory rate 22, temperature 36.4. 99% on four liters nasal cannula. General appearance: This is a cachectic male. Lungs sounds were significant for good air entry bilaterally with vesicular breath sounds, no rhonchi or wheeze appreciated. Cardiovascular significant for a tachycardia. otherwise unremarkable. b Over the mid sternum at around T3 is a 1 cm round red maculopapular lesion; no pus from the site.

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Jeff, I see airspace disease in the left, some volume loss, and a whole bunch of mediastinal soft tissue density (not fat?) that doesn't belong there. It also looks like either a very large pericardial effusion or extensive soft tissue infiltration of the mediastimum.

How this fits in with a boil and "rule out endobronchial obstruction" is hard to piece together. The CT alone lookes like small cell cancer or perhaps some trapped lung from an empyema with a brisk mediastinal soft tissue reaction. I'd like to hear what the rest of the CT looked like, or see it preferably, but if the guy had symptoms of an infection I'd make sure to cover styaph and anaerobes, then if he didn't improve quickly I'd take a look in the airway, but that really depends on what else is on the CT.

I didn't put up a lot of the slices, but essentially we have 1. loculated fluid collection in anterior mediastinum and also some enhancement seen posterior to the right sternoclavicular joint 2. moderate sized pericardial effusion. 3. left upper lobe collapse with air bronchograms.

We have himn on broad coverage abx.

update: CT surg consult drained the "boil" and sent off purulent-appearing fluid for micro. They said it did NOT communicate down into the mediastinum which is what I was originally concerned about.

An echo is pending. Again, he is quite hemodynamically stable but cachectic appearing. More to follow...

Would still be concerned for actinomycosis.(alcoholic)vs Nocardia. Looks like a necrotizing pneumonia with parapneumonic loculated effusion/pericardial eff.with left lower lobe atelectasis on CT. Will likely need a VATS. FOB to address LLL collapse and cultures.